Form C-4 "New Jersey Acute Care Hospitals Cost Reports - Cost Center Budgets Reconciling Items (Rit)" - New Jersey

What Is Form C-4?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form C-4 "New Jersey Acute Care Hospitals Cost Reports - Cost Center Budgets Reconciling Items (Rit)" - New Jersey

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NEW JERSEY ACUTE CARE HOSPITALS
C-4
2020
COST REPORTS
Hospital: __________________________________________
Do not change any preprinted
COST CENTER BUDGETS
Hospital Number: |_____|_____|_____|_____|
wording on this form.
RECONCILING ITEMS (RIT)
Hours (Whole Numbers)
Costs ($000’s)
A
B
C
D
E
F
G
H
I
J
K
L
M
Reconciling Items (1)
Physicians
Salaries
Phys.
Cont.
Other
Dep. &
Lease
Exp.
Total
Employees
Supplies
Fees
Serv.
Exp.(2)
Fac. Int.
Costs
Rec.
Cost
Salaries
Fees
Employees
Physicians
1
Bad Debt Provision
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
1
2
Coffee and Gift Shops
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
2
3
Retail Operations
3
4
Purchased Cost of Blood (3)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
4
5
Other (4)
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
24
TOTALS
24
FOOTNOTES:
(1)
Enter, by cost classification(s), the costs of items excluded by definition from cost center budgets. Totals (Line 24), should agree with Reconciling Items (Line 52) on Form C.
These amounts when added to the totals of all other cost centers, should equal Total Institution hours and costs (Form C, Line 53).
(2)
Include fringes applicable to salaries under "Oth. Exp."
(3)
Should only include the element of cost related to the payment of donors.
(4)
Provide itemized listing. Do NOT include allowable Rebundled Service Costs.
NEW JERSEY ACUTE CARE HOSPITALS
C-4
2020
COST REPORTS
Hospital: __________________________________________
Do not change any preprinted
COST CENTER BUDGETS
Hospital Number: |_____|_____|_____|_____|
wording on this form.
RECONCILING ITEMS (RIT)
Hours (Whole Numbers)
Costs ($000’s)
A
B
C
D
E
F
G
H
I
J
K
L
M
Reconciling Items (1)
Physicians
Salaries
Phys.
Cont.
Other
Dep. &
Lease
Exp.
Total
Employees
Supplies
Fees
Serv.
Exp.(2)
Fac. Int.
Costs
Rec.
Cost
Salaries
Fees
Employees
Physicians
1
Bad Debt Provision
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
1
2
Coffee and Gift Shops
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
2
3
Retail Operations
3
4
Purchased Cost of Blood (3)
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
/ / / / / / /
4
5
Other (4)
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
24
TOTALS
24
FOOTNOTES:
(1)
Enter, by cost classification(s), the costs of items excluded by definition from cost center budgets. Totals (Line 24), should agree with Reconciling Items (Line 52) on Form C.
These amounts when added to the totals of all other cost centers, should equal Total Institution hours and costs (Form C, Line 53).
(2)
Include fringes applicable to salaries under "Oth. Exp."
(3)
Should only include the element of cost related to the payment of donors.
(4)
Provide itemized listing. Do NOT include allowable Rebundled Service Costs.